Scoliosis is a curving of the spine. The spine curves away from the middle or sideways. Scoliosis (from Greek: skoliosis meaning "crooked") is a medical condition in which a person's spine is curved from side to side. Although it is a complex three-dimensional deformity, on an X-ray, viewed from the rear, the spine of an individual with scoliosis may look more like an "S" or a "C" than a straight line.
Scoliosis is typically classified as either congenital (caused by vertebral anomalies present at birth), idiopathic (cause unknown, subclassified as infantile, juvenile, adolescent, or adult, according to when onset occurred), or neuromuscular (having developed as a secondary symptom of another condition, such as spina bifida, cerebral palsy, spinal muscular atrophy, or physical trauma). This condition affects approximately seven million people in the United States.
It has been estimated that approximately sixty five percent of scoliosis cases are idiopathic, approximately fifteen percent are congenital and approximately ten percent are secondary to a neuromuscular disease.
In adolescent idiopathic scoliosis, there is no clear causal agent and it is generally believed to be multifactorial, although genetics are believed to play a role. Various causes have been implicated, but none of them have consensus among scientists as the cause of scoliosis, though the role of genetic factors in the development of this condition is widely accepted. Still, at least one gene, notably ( CHD7), has been associated with the idiopathic form of scoliosis.
In some cases, scoliosis exists at birth due to a congenital vertebral anomaly.
Scoliosis secondary to neuromuscular disease may develop during adolescence, such as with tethered spinal cord syndrome. Scoliosis often presents itself, or worsens, during the adolescence growth spurt and is more often diagnosed in females versus males.
Signs and symptoms
Patients having reached skeletal maturity are less likely to have a worsening case. Some severe cases of scoliosis can lead to diminishing lung capacity, putting pressure on the heart, and restricting physical activities.
The signs of scoliosis can include:
- Uneven musculature on one side of the spine
- A rib prominence and/or a prominent shoulder blade, caused by rotation of the ribcage in thoracic scoliosis
- Uneven hips/leg lengths
- Slow nerve action (in some cases)
Scoliosis is sometimes associated with other conditions such as Ehlers–Danlos syndrome (hyperflexibility, "floppy baby" syndrome, and other variants of the condition), Charcot–Marie–Tooth disease, Prader–Willi syndrome, kyphosis, cerebral palsy, spinal muscular atrophy, muscular dystrophy, familial dysautonomia, CHARGE syndrome, Friedreich's ataxia, Fragile X syndrome, proteus syndrome, spina bifida, Marfan's syndrome, neurofibromatosis, connective tissue disorders, congenital diaphragmatic hernia, hemihypertrophy, and craniospinal axis disorders (e.g., syringomyelia, mitral valve prolapse, Arnold–Chiari malformation), and Amniotic Band Syndrome (ABS).
Scoliosis associated with known syndromes such as Marfan's or Prader–Willi is often sub-classified as "syndromic scoliosis."
Treatment depends on the cause of the scoliosis, the size and location of the curve, and how much more growing the patient is expected to do. Most cases of adolescent idiopathic scoliosis (less than 20 degrees) require no treatment, but should be checked often, about every 6 months.
As curves get worse (above 25 to 30 degrees in a child who is still growing), bracing is usually recommended to help slow the progression of the curve. There are many different kinds of braces used. The Boston Brace, Wilmington Brace, Milwaukee Brace, and Charleston Brace are named for the centers where they were developed.
- Each brace looks different. There are different ways of using each type properly. The selection of a brace and the manner in which it is used depends on many factors, including the specific characteristics of the curve. The exact brace will be decided on by the patient and health care provider.
- A back brace does not reverse the curve. Instead, it uses pressure to help straighten the spine. The brace can be adjusted with growth. Bracing does not work in congenital or neuromuscular scoliosis, and is less effective in infantile and juvenile idiopathic scoliosis.
The choice of when to have surgery will vary. After the bones of the skeleton stop growing, the curve should not get much worse. Because of this, the surgeon may want to wait until your child’s bones stop growing. But your child may need surgery before this if the curve in their spine is severe or is getting worse quickly. Curves of 40 degrees or greater usually require surgery.
Surgery involves correcting the curve (although not all the way) and fusing the bones in the curve together. The bones are held in place with one or two metal rods held down with hooks and screws until the bone heals together. Sometimes surgery is done through a cut in the back, on the abdomen, or beneath the ribs. A brace may be required to stabilize the spine after surgery.
The limitations imposed by the treatments are often emotionally difficult and may threaten self-image, especially in teenagers.
Physical therapists and orthotists (orthopedic appliance specialists) can help explain the treatments and make sure the brace fits comfortably.
Spinal fusion with instrumentation
Spinal fusion is the most widely performed surgery for scoliosis. In this procedure, bone (either harvested from elsewhere in the body autograft or from a donor allograft) is grafted to the vertebrae so that when it heals they will form one solid bone mass and the vertebral column becomes rigid. This prevents worsening of the curve, at the expense of some spinal movement. This can be performed from the anterior (front) aspect of the spine by entering the thoracic or abdominal cavity or, more commonly, performed from the back (posterior). A combination is used in more severe cases.
Spinal fusions were once performed without metal implants. In this technique, a cast was applied after the surgery, usually under traction to pull the curve as straight as possible and then hold it there while fusion took place. Casting left patients largely immobilized for a period of weeks to months, with significant burden on patient quality of life. Additionally, there was a relatively high risk of pseudarthrosis (fusion failure) at one or more levels, and significant correction could not always be achieved.
In 1962, Paul Harrington introduced a metal spinal system of instrumentation that assisted with straightening the spine, as well as holding it rigid while fusion took place. The original (now obsolete) Harrington rod operated on a ratchet system, attached by hooks to the spine at the top and bottom of the curvature that when cranked would distract, or straighten, the curve. The Harrington rod represented a major advance in the field, as it obviated the need for prolonged casting, allowing patients greater mobility in the post-operative period and significantly reducing the quality of life burden of fusion surgery. Additionally, as the first system to apply instrumentation directly to the spine, the Harrington rod was the precursor to most modern spinal instrumentation systems. A major shortcoming of the Harrington method was that it failed to produce a posture wherein the skull would be in proper alignment with the pelvis, and it did not address rotational deformity. As a result, unfused parts of the spine would try to compensate for this in the effort to stand up straight. As the person aged, there would be increased wear and tear, early-onset arthritis, disc degeneration, muscular stiffness, and pain with eventual reliance on painkillers, further surgery, inability to work full-time, and disability. "Flatback" became the medical name for a related complication, especially for those who had lumbar scoliosis.
Modern spinal systems are attempting to address sagittal imbalance and rotational defects unresolved by the Harrington rod system. They involve a combination of rods, screws, hooks, and wires fixing the spine, and can apply stronger, safer forces to the spine than the Harrington rod. This technique is known as the Cotrel-Dubousset instrumentation, currently the most common technique for the procedure.
In general, modern spinal fusions have good outcomes with high degrees of correction and low rates of failure and infection. Patients with fused spines and permanent implants tend to have normal lives with unrestricted activities when they are younger; it remains to be seen whether those that have been treated with the newer surgical techniques develop problems as they age.
Pedicle screw-only posterior spinal fusion may improve major curve correction at two years among patients with adolescent idiopathic scoliosis (AIS) as compared to hybrid instrumentation (proximal hooks with distal pedicle screws) (65% versus 46%) according to a retrospective matched cohort study.
A complementary surgical procedure a surgeon may recommend is called thoracoplasty (also called costoplasty). This is a procedure to reduce the rib hump that affects most scoliosis patients with a thoracic curve. A rib hump is evidence that there is some rotational deformity to the spine. Thoracoplasty may also be performed to obtain bone grafts from the ribs instead of the pelvis, regardless of whether a rib hump is present. Thoracoplasty can be performed as part of a spinal fusion or as a separate surgery, entirely.
Thoracoplasty is the removal (or resection) of typically four to six segments of adjacent ribs that protrude. Each segment is one to two inches long. The surgeon decides which ribs to resect based on either their prominence or their likelihood to be realigned by correction of the curvature alone. The ribs grow back, and will grow back straight.
Thoracoplasty has risks, such as increased pain in the rib area during recovery or reduced pulmonary function (10–15 percent is typical) following surgery. This impairment can last anywhere from a few months to two years. Because thoracoplasty may lengthen the duration of surgery, patients may also lose more blood or develop complications from the prolonged anesthesia. A more significant, though far less common, risk is that the surgeon will inadvertently puncture the pleura, a protective coating over the lungs. This could cause blood or air to drain into the chest cavity, conditions called a haemothorax or pneumothorax, respectively.
The risk of undergoing surgery for scoliosis is estimated to be five percent. Possible complications may be inflammation of the soft tissue or deep inflammatory processes, breathing impairments, bleeding and nerve injuries. However, according to the latest evidence, the rate of complications is far higher. As early as five years after surgery another five percent require reoperation and today it is not yet clear what to expect from spine surgery in the long-term. Taking into account that signs and symptoms of spinal deformity cannot be changed by surgical intervention, surgery remains primarily a cosmetic indication, only especially in patients with adolescent idiopathic scoliosis (AIS), the most common form of scoliosis never exceeding eighty degrees. However, the cosmetic effects of surgery are not necessarily stable.
Surgery without fusion
New implants that aim to delay spinal fusion and to allow more spinal growth in young children have been developed. For the youngest patients, whose thoracic insufficiency compromises their ability to breathe and applies significant cardiac pressure, ribcage implants that push the ribs apart on the concave side of the curve may be especially useful. These vertical expandable prosthetic titanium ribs (VEPTR) provide the benefit of expanding the thoracic cavity and straightening the spine in all three dimensions while allowing it to grow.
Although these methods are novel and promising, these treatments are suitable only for growing patients. Spinal fusion remains the "gold standard" of surgical treatment for scoliosis.
The traditional medical management of scoliosis is complex and is determined by the severity of the curvature and skeletal maturity, which together help predict the likelihood of progression.
The conventional options are, in order:
- Physical Therapy
- Occupational Therapy
- Chiropractic or Osteopathic Therapy
- Casting (EDF)
A growing body of scientific research testifies to the efficacy of specialized treatment programs of physical therapy, which may include bracing. Debate in the scientific community about whether chiropractic and physical therapy can influence scoliotic curvature is partly complicated by the variety of methods proposed and employed: Some are supported by more research than others.
The Schroth method is a noninvasive, physiotherapeutic treatment, which has been used successfully in Europe since the 1920’s. Originally developed in Germany by scoliosis sufferer Katharina Schroth, this method is now taught to scoliosis patients in clinics specifically devoted to Schroth therapy in Germany, Spain, England, and North America. The method is based upon the concept of scoliosis as resulting from a complex of muscular asymmetries (especially strength imbalances in the back) that can be at least partially corrected by targeted exercises.
The Schroth method has proven effective at reversing abnormal scoliotic curvatures by an average of ten percent in 4- to 6-week in-patient programs, and by thirty percent or more in an out-patient program over a period of a year. One study of nearly 200 adolescent Schroth patients found no curve progression three years following the in-patient program. Several studies have documented the Schroth method's efficacy in substantially reducing or eliminating pain, which tends to be a problem, in particular, for adults.
Small curvatures between fifteen and twenty degrees during growth may be treated with the physio-logic-program, curvatures between twenty and thirty degrees during growth spurt with "3D-made-easy". This program has been tested in the environment of in-patient treatment as well. In curvatures exceeding thirty degrees , a combination of the methods described together with the Schroth program may be helpful, and a specialized centre with trained and certified staff should be taken into account. Out-patient rehabilitation treatments today may reach the same outcome as in-patient programs. Out-patient programs may be successful when pattern-specific programs are provided. A certain intensity is necessary to allow the very best compliance with conservative treatment, and to acquire strategies for coping with scoliosis and with the conservative treatment.
The indications for treatment depend on degree of curvature, maturity of the patient, and the individual curve pattern. While evidence supporting such conservative, non-invasive treatments is weak, today conservative management of scoliosis can be regarded as being evidence-based; no substantial evidence has been found to support surgical intervention.
An occupational therapist (OT) helps those having experienced an injury or illness regain or maintain the ability to participate in their everyday activities. For those with scoliosis, an occupational therapist can provide assistance through assessment, intervention, and ongoing evaluation of the condition, which will help them manage physical symptoms so they can participate in daily activities, such as those in self-care, productivity, and leisure.
One intervention involves bracing. During the past several decades, a large variety of bracing devices have been developed for the treatment of scoliosis. Studies demonstrate that presenting force sideways across a joint by bracing prevents further curvature of the spine in idiopathic scoliosis, while other studies have also shown that braces can be used by individuals with scoliosis during physical activities.
Other interventions include postural strategies such as posture training in sitting, standing, and sleeping positions and in using positioning supports such as pillows, wedges, rolls, and corsets.
Adaptive and compensatory strategies are also employed to help facilitate individuals to return to daily activities.
Disability caused by scoliosis, as well as physical limitations during recovery from treatment related surgery, often affects an individual’s ability to perform self-care activities. One of the first treatments of scoliosis is the attempt to prevent further curvature of the spine. Depending on the size of the curvature, this is typically done in one of three ways: bracing, surgery, or postural positioning through customized cushioning. Stopping the progression of the scoliosis can prevent the loss of function in many activities of daily living by maintaining range of motion, preventing deformity of the rib cage, and reducing pain during activities such as bending or lifting.
Occupational therapists are often involved in the process of selection and fabrication of customized cushions. These individualized postural supports are used to maintain the current spinal curvature, or they can be adjusted to assist in the correction of the curvature. This type of treatment can help to maintain mobility for a wheelchair user by preventing the deformity of the rib cage and maintaining an active range of motion in the arms.
For other self-care activities (such as dressing, bathing, grooming, personal hygiene, and feeding), several strategies can be used as a part of occupational therapy treatment. Environmental adaptations for bathing could include a bath bench, grab bars installed in the shower area, or a handheld shower nozzle. For activities such as dressing and grooming, various assistive devices and strategies can be used to promote independence. An occupational therapist may recommend a long-handled reacher that can be used to assist independent dressing by allowing a person to avoid painful movements such as bending over; a long-handled shoehorn can be used for putting on and removing shoes. Problems with activities such as cutting meat and eating can be addressed by using specialized cutlery, kitchen utensils, or dishes.
Productive activities include paid or unpaid work, household chores, school, work, and play. Recent studies in healthcare have led to the development of a variety of treatments to assist in the management of scoliosis thereby maximizing productivity for people of all ages. Assistive technology has undergone dramatic changes over the past 20 years; the availability and quality of the technology has improved greatly. As a result of using assistive technology, functional changes may range from improvements in abilities, performance in daily activities, participation levels, and quality of life.
A common assistive technology intervention is specialized seating and postural control. It is widely known that, for children with poor postural control, a comfortable seating system that provides them with the support needed to maintain a sitting position can be essential for raising their overall level of well-being. A child's well-being in a productive sense involves the ability to participate in classroom and play activities. Specialized wheelchair seating has been identified as the most common prescription in the management of scoliosis in teenagers with muscular dystrophy.
With comfortable wheelchair seating, teenagers are able to participate in classroom activities for longer periods with less fatigue. By tilting the seating position twenty degrees forward (toward the thighs), seating pressure is significantly redistributed, and, therefore, sitting is more comfortable. If an office worker with scoliosis can sit for longer periods, increased work output is likely to occur and could improve quality of life. Tall, forward sloping seats or front parts of seats, and when possible with tall desk with the opposite slope, can, in general, reduce pains and the need of bending significantly while working or studying, and that is particularly important with braced, fragile, or tender backs. And open hip angle can benefit the used lung volume and respiration.
For those not using a wheelchair, bracing may be used to treat scoliosis. Lifestyle changes are made to compensate for the proper use of spine braces.
There are many physical symptoms that can prevent a person from engaging in physical leisurely activities, such as chest pains, back pains, shortness of breath, and limited spinal movement. The OT's role is to help individuals with scoliosis manage these physical symptoms so they can participate in physical leisure activities.
Bracing is a common strategy recommended by an OT, in particular, for individuals engaging in sports and exercise. An OT is responsible for educating an individual on the advantages and disadvantages of different braces, proper ways to wear the brace, and the day-to-day care of the brace.
To help a person manage heart and lung symptoms such as shortness of breath or chest pains, an occupational therapist can teach the individual energy conservation techniques. This includes scheduling routine breaks during the activity, as suitable for the individual. For example, an occupational therapist can recommend that a swimmer take breaks between laps to conserve energy. Other energy conservation strategies knowing the benefits of scheduled rest and efficient breathing techniques. Adapting or modifying the exercise or sport is another way a person with scoliosis can do it. Adapting the activity may change the difficulty of the sport or exercise. For example, it might mean taking breaks throughout an exercise. If a person with scoliosis is unable to participate in a sport or exercise, an OT can help the individual explore other physical activities that are suitable to his/her interests and capabilities. An OT and the person with scoliosis can explore enjoyable and meaningful participation in the sport/exercise in another capacity, such as coaching or refereeing.
A scoliosis spinal columns curve of 10° or less affects 1.5% to 3% of individuals. The prevalence of curves less than 20° is about equal in males and females. It is most common during late childhood, in particular, in girls.
The outcome depends on the cause, location, and severity of the curve. The greater the curve, the greater the chance the curve will get worse after growth has stopped.
The greater the initial curve of the spine, the greater the chance the scoliosis will get worse after growth is complete. Severe scoliosis (curves in the spine greater than 100 degrees) can cause breathing problems.
Mild cases treated with bracing alone do very well. People with these kinds of conditions tend not to have long-term problems, except an increased rate of low back pain when they get older. People with surgically corrected idiopathic scoliosis can do very well and can lead active, healthy lives.
Patients with neuromuscular scoliosis have another serious disorder (like cerebral palsy or muscular dystrophy) so their goals are much different. Often the goal of surgery is simply to allow a child to be able to sit upright in a wheelchair.
Babies with congenital scoliosis have a wide variety of underlying birth defects. Management of this disease is difficult and often requires many surgeries.
- Emotional problems or lowered self-esteem may occur as a result of the condition or its treatment (specifically, wearing a brace)
- Failure of the bone to join together (very rare in idiopathic scoliosis)
- Low back arthritis and pain as an adult
- Respiratory problems from severe curve
- Spinal cord or nerve damage from surgery or severe, uncorrected curve
- Spine infection after surgery
Cannabinoids (CBD) Treat Scoliosis
The Definition of Chronic Pain
Although “chronic pain” seems all encompassing and thus easily used as a reason for medical marijuana use, the organization of Health Canada very clearly defines what can be considered severe enough pain for medical marijuana. With that said, there are many suffering from chronic pain – due to a variety of reasons – with grants for the medical use of cannabis.
Arthritis, headaches and back pain are the most common, but fibromyalgia, carpal tunnel syndrome, neuropathy and phantom limb pain are also common reason for chronic pain. Continuing pain can also be caused by debilitating illnesses such as MS (multiple sclerosis), scoliosis, osteoporosis and others.
For many, medical marijuana use is a “last resort”, used only after several pharmacologic treatments fail. Typically, the first treatments include pain relievers such as aspirin or ibuprofen. Unfortunately, long-term use can cause serious side effects; even if there is pain relief, it can only be in short periods due to the need for short-term use of the “first line” of treatments.
Should the first treatments fail, narcotic opioids such as codeine, morphine and oxycodone are generally prescribed. Although often highly affective, the concern for these types of narcotics is that they have a high possibility for addiction and abuse. As well, their use is also limited, due to possible side effects in higher doses. The withdrawal symptoms for addictive pharmaceuticals can be mild to painfully severe.
For those that don’t respond to the first or second line of treatments, medical marijuana may be prescribed. As well, there are those who prefer not to use man-made pharmaceuticals that have a high rate of addiction or serious side effects.
Many studies have found cannabinoids are integral to the body's pain mechanisms. Other studies suggest cannabinoids work with other pain medications like opiates to provide pain relief at lower dosages. In addition, patients with cancer, multiple sclerosis, and other ailments attest that marijuana helps ease their pain, often allowing them to cease or lessen the use of drugs with more profound side effects. The U.S. Society for Neuroscience has concluded that, "careful studies show that cannabinoids directlly interfere with pain signaling in the nervous system. The insights may lead to a new class of pain killers."
The available evidence from animal and human studies indicates that “cannabinoids can have a substantial analgesic effect."
Cannabinoids are indicated for:
- Postoperative pain patients (using cannabinoids as an opioid adjunct to determine whether nausea and vomiting from opioids are reduced).
- Patients with spinal cord injury, peripheral neuropathic pain, or central post-stroke pain.
- Patients with chronic pain and insomnia.
Most neuromuscular diseases are incurable. However, an effective rehabilitation program can help maintain a patient's quality of life, as well as maximize the patient's physical and psychosocial functions. An effective rehabilitation program can also minimize secondary medical comorbidity, prevent or limit physical deformity, and allow the patient to integrate into society. Modalities such as range of motion and strengthening exercise, along with bracing and appropriate surgical intervention, may prolong ambulation. Today, adaptive devices such as wheelchairs and lifts are now often interfaced with computer technology, providing better strategies for improving the patient's mobility.
Cannabidiol —CBD— is a compound in Cannabis that has medical effects but does not make people feel “stoned” and actually counters some of the effects of THC. After decades in which only high-THC Cannabis was available, CBD-rich strains are now being grown by and for medical users.
The reduced psychoactivity of CBD-rich Cannabis may make it an appealing treatment option for patients seeking anti-inflammatory, anti-pain, anti-anxiety and/or anti-spasm effects without disconcerting euphoria or lethargy.
Scientific and clinical studies indicate that CBD could be effective in easing symptoms of a wide range of difficult-to-control conditions. CBD has demonstrated neuroprotective effects, and its anti-cancer potential is currently being explored at several academic research centers in the U.S. and other countries.
Approximately one in 750 samples of Cannabis being grown for medical use is turning out to be CBD-rich. (For data collection purposes, "CBD-rich" has been defined as 4% or more by dry weight). Doctors and patients now have a unique opportunity to evaluate its effects.
Currently, there are two very different certified tinctures:
1. CBD tincture: 5 mg/cc CBD and 5 mg/cc THC.
2 THC tincture: 11 mg/cc THC and 2 mg/cc CBD.
A little CBD seems to prevent THC toxicity (paranoia, anxiety, etc.).
These balanced THC/CBD tinctures, where the CBD is at least 4 mg/cc, are truly amazing.
Amazing results are achieved (nearly 100 %) using a tincture with only 2 mg./cc of CBD given twice daily.
An interesting sidebar: the Federal Government patented CBD in 2003!
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